HomeMy WebLinkAboutSeptic Pumping Slip - 351 WILLOW STREET 4/6/2017 (2)Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
tab
System Location:,
Address
North Andover
City/Town
2. System Owner:
Name a
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Component:
Other (describe):
Date 2. Quantity Pumped:
Gallons
❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
u69C
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed c ndition of component pumped:
6. S ; e- -"umped By:
ate_` arts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
0 .t bradford ma
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
ignature of I-1911e
nature of Receiving Facility (or attach facility receipt)
3
Date
Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other fLr1Lns maybe used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
System Location:
35 1,,C1�
Address
North Andover
City/Town
2. System Owner:
State Zip Code
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record II
1. Date of Pumping 3� I 2. Quantity Pumped:
Date Gallons
3. Component: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
E Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed ondition of component pumped:
If yes, was it cleaned? ❑ Yes ❑ No
ped By:
is 58 So Kimball S
Bradford Ma
7. Location where contents were disposed:
st bradford ma
Signature of er
Signature of Receiving Facility (or attach facility receipt)
Vehicle License Number
Date
Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1. System Location:
on the computer, 3S. [r '�
use only the tab I
key to move your Address
cursor - do not North Andover
use the return
key City/Town
2. System Owner:
i��
Name
State Zip Code
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
(CCC)
Gallons
3. Component: ❑ Cesspool(s) ❑ Septic
Tank ❑ Tight Tank ❑ Grease Trap
ElOther (describe):
lief ', jh si
1. Date of Pumping
Date
2. Quantity Pumped:
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Observed co dition of component pumped:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
ice# bradford ma
Signature of Hauler
Vehicle License Number
Date
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms 1.
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key
lab
It(bl
i
System Location:
Address
North Andover
City/Town
2. System Owner:
Name
6�
State Zip Code
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quantity Pumped:
3. Component: ❑ Cesspool(s) ❑ Septic Tank
° Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed cofldition of component pumped:
Stewarts Septic 58 So Kimball St Bradford Ma
Company
7. Location where contents were disposed:
radford ma
ignature of Hauler
Signature of Receiving Facility (or attach facility receipt)
Gallons
❑ Tight Tank ❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1